Instructions an Issue in Missed Ectopic Claim
A recent malpractice claim involved a 30-year-old woman who complained of severe lower abdominal pain and vomiting. She told both the triage nurse and the emergency physician (EP): "This feels just like the pain I experienced several months ago when I had kidney stones."
"She denied having any urinary symptoms, and estimated that her last menstrual period had occurred one month earlier," says John J. Barton, JD, a partner in the Providence, RI, office of Barton Gilman. "She failed to mention that she had had a history of a prior ectopic pregnancy."
Upon reviewing the patient’s medical chart for prior ED visits, the EP noted that the patient had been treated five times for kidney stones within the previous three years. No information about the prior ectopic pregnancy was referenced in the records available to the doctor.
"On examination, the physician noted that the patient had normal vital signs, and mild tenderness on palpation of her mid and lower abdomen," says Barton. "She denied having any flank pain, and all other physical findings appeared to be normal."
The EP ordered a complete blood count, a metabolic screen, lipase, and urinalysis. "He also ordered an HCG pregnancy test, to be followed by an abdominal CT scan if the pregnancy test was negative," says Barton.
All blood study findings came back as normal, except for the white blood count, which was elevated at 14.98, and the creatine level, which was low at .49. The results of the urinalysis and HCG pregnancy test were not reported in the record. "It was later discovered that these tests were never performed, though the physician’s order had been initialed by a member of the nursing staff as confirmation of those tests having been performed," says Barton.
Despite this oversight, the patient was taken to radiology for an abdominal CT scan. "The radiologist who interpreted the CT scan verbally reported to the ER physician that the abdominal scan showed no evidence of genitourinary obstruction, but did reveal a small amount of perihepatic fluid in the subscapular area," says Barton.
The formal written report on the CT scan, which was posted three hours later, after the physician last re-examined the patient, reported an additional finding of "free fluid in the pelvis, which may represent blood."
When the patient was re-examined by the EP, she reported that her abdominal pain had diminished, but was still present. The physician ordered pain medication and an anti-nausea medication. Based on the patient’s history, physical examination, and lab results, the EP concluded that the patient’s resolving abdominal pain was likely due to a kidney stone that had passed.
"He assumed that the pregnancy test he had ordered had in fact been done and was negative," says Barton. "This assumption was based on the fact that the nurse had initialed his order and that the staff had proceeded to take the patient to radiology for the CT scan."
Nevertheless, the EP elected to monitor the patient for a further period of time before she was released. Two hours later, the patient was cleared by the physician for discharge. At that time, her condition was described by the nursing staff as "stable" and "improved."
"The physician did not see the patient at the time of discharge, but he did sign the discharge orders," says Barton. The discharge orders instructed the patient to "take one 324 mg tablet of [oxycodone and acetaminophen] every four to six hours as needed, and to follow up in two days with your regular treating physician," and were delivered to the patient by the nursing staff.
Seven hours later, the patient was brought back to the ED by ambulance, suffering from severe abdominal pain and seizures. An HCG pregnancy test performed at the time of the second admission was positive.
An exploratory laparotomy confirmed the ectopic pregnancy, a uterine fundal rupture, and a 10 cm blood clot containing chorionic villi and fragments of placental tissue. "The patient required multiple transfusions, and suffered the loss of one of her fallopian tubes," says Barton. "She was discharged after a five-day hospitalization," says Barton.
The patient filed suit against the EP and the hospital. No members of the hospital’s nursing staff or radiology department were named as defendants.
"However, the patient asserted vicarious liability claims against the hospital based on the acts and omissions of these staff members," says Barton. "Ultimately, the lawsuit was settled by the hospital’s carrier on behalf of all defendants for an undisclosed amount."
Here are two of the plaintiff attorney’s allegations:
• That the EP, not the nurse, should have handled the patient’s discharge.
The plaintiff attorney was highly critical of the fact that the EP did not personally check on the patient at the time of discharge, but instead had a nurse pass along the discharge instructions.
"Counsel argued that if the physician had seen the patient at the time of discharge and accessed the chart one last time, he might have noted that the HCG pregnancy test had never been performed," says Barton.
The plaintiff’s attorney also argued that had the EP accessed the chart just prior to discharge, he might have seen the formal CT scan report, which noted "free fluid in the pelvis which may represent blood."
"Had he taken five or 10 minutes to personally deliver the discharge instructions, the patient might have felt more respected and less abandoned," adds Barton. "Studies of malpractice cases have consistently shown that patients who believe that their doctors care about them as people, and not just as patients, are much less likely to sue."
The EP may not always be able to handle the discharge personally, acknowledges Barton, "but lawsuits are also time-consuming and inconvenient for ED personnel. Finding time to do the discharge saves more time and aggravation later."
• That the EP should have instructed the patient to return to the ED if symptoms persisted or worsened.
"Telling the patient to follow up with her regular treating physician in two days, as was done in the above case, does the patient no good if her uterus is in the process of rupturing from an ectopic pregnancy," says Barton.
In addition, Barton says that telling the patient to follow up with someone else is "the kind of instruction which can easily be recharacterized as buck passing’ by a clever plaintiff’s attorney."